Health | The Atlantic

When Kelli Kelley awoke from her C-section 17 years ago, having delivered her son after just 24 weeks of pregnancy, her husband gave her a Polaroid of their baby. He was tiny, underdeveloped, eyes still fused shut, with translucent skin covered in fine hair, and lying in a sea of medical equipment and lines. To Kelley, he looked like a baby bird. Cut to her first visit to the neonatal intensive-care unit (NICU) to meet him: a cacophony of beeping machines, harsh lighting, “space-age-looking equipment,” and hospital smells, with 40 “tiny, alien babies in boxes.” Her son had a whole team of doctors and nurses working to keep him alive, but Kelley felt frightened and alone. Kelley remembers just one support group for parents, with a chaplain. “Sitting with a man in a collar felt more like a memorial service,” she recalls.

Four months later Kelley and her husband brought their son home. He was on a heart monitor and still unable to breastfeed. They lived under a crush of medical bills, and in his first year, their baby underwent three surgeries. Kelley didn’t recognize the toll her son’s ordeal had taken on her until two years later when their daughter was born at 34 weeks with a blood disorder. The family returned to the NICU, and for Kelley, the trauma from both births collided. Kelley was diagnosed with an anxiety disorder; but her son was already five before Kelley finally received a post-traumatic stress disorder diagnosis.

“The experience of the neonatal intensive-care unit, the birth of a premature baby—it’s a very different kind of trauma from what we call single-incident trauma, like someone in a car accident or even a sexual assault,” explains Richard J. Shaw, a professor of psychiatry and pediatrics at Stanford University’s Lucile Packard Children’s Hospital. In the NICU, traumatic, stressful events are continuous: your baby’s fragile health, other babies coding, a flow of bad news about your baby’s current health and future prognosis. Mothers—themselves still recovering from childbirth—commonly describe guilt, feeling as though they’d somehow failed their children by giving birth early (even though, of course, they couldn’t help it), and a sense of uselessness in the shadow of a medical team of experts. Only in recent years have researchers begun recognizing that the fear, stress, and anxiety parents carry with them out of the NICU can manifest later as PTSD.

Shaw, who has researched PTSD in mothers of premature babies, notes that very few NICUs have dedicated psychiatrists on staff. While screening for postpartum depression has become common—and rates of PPD in mothers of premature infants can be as high as 40 percent—PTSD screenings for NICU parents are still rare. Even among fathers of preemies who did not meet the criteria for PTSD shortly after the birth, one study found that many did experience PTSD symptoms after about four months (once the baby was home).

When Kelley needed help and began searching for it, she found little. So she started a program to train people she calls “NICU graduate parents” to support other families with children in the NICU in her hometown of Austin, Texas. That program eventually became a stand-alone nonprofit, Hand to Hold, and has grown to comprise a network of up to 200 peer-support volunteers (dubbed Helping Hands) across the United States, England, South Africa, Canada, the Virgin Islands, Japan, and Puerto Rico. Those Helping Hands undergo intake screening to help ensure they are ready to reenter the NICU; are given a background check; must complete a four-part, online training on effective listening, bereavement, and trauma-informed care; have an interview with Hand to Hold’s peer-support team; and also receive ongoing support from Hand to Hold’s staff of social workers. Helping Hands are paired with current NICU parents based on the similarity of their babies’ conditions and their experiences in the NICU. (Parents of 23-weekers are matched with other parents of 23-weekers, for example.) This free program offers parents a person to call, text, and email who knows what it’s like to navigate life in the NICU. A separate Hand to Hold “ambassadors” program places peer volunteers in person in the NICU to go on rounds with medical teams and lead parent and sibling support groups at three Texas medical centers.

Peer support is a useful method for treating PTSD. “Speaking to a parent who’s been through something similar and learned how to cope with it is tremendously powerful,” Shaw says. Writing a trauma narrative is also common practice, which in a clinical setting might include writing out a full story of the traumatic event, and going through paragraph by paragraph to consider the feelings those memories arouse—perhaps two or three times. When such a therapeutic setting is unavailable, there’s evidence that writing for 20 minutes a day about one’s trauma can relieve distress, anger, and anxiety, and somewhat reduce PTSD symptoms.

A core element of Hand to Hold’s programming is the opportunity for parents to write for the organization’s blog—which can help the writer process, but is also beneficial as a resource for other NICU parents. Kayla Aimee delivered her daughter at 25 weeks and found Hand to Hold during a search for micro-preemie support groups. She started blogging and eventually published the book Anchored: Finding Hope in the Unexpected.

Andrea Mullenmeister was 23 weeks pregnant and on vacation in northern Minnesota when her contractions started. After a rush to the nearest hospital, Mullenmeister was so dilated that her baby’s foot was visible by vaginal exam. So Mullenmeister was airlifted by helicopter to the nearest hospital with a NICU. She could hardly breathe as lakes, cityscapes, and countryside flicked past the windows. Her husband followed in their car below. Mullenmeister’s son was born bruised, small, and battered, foot-first, not breathing. Once doctors got him breathing, “I heard this tiny mew,” she says. But his traumatic birth and the subsequent 93 days in the NICU left a firm impression, giving Mullenmeister a fear of heights and flashbacks for years when she heard helicopters. It was two years before Mullenmeister was diagnosed with late-onset postpartum depression and PTSD. Around that time she found Hand to Hold and started writing about her experience on the organization’s blog. In addition to therapy, she explained, that habit of writing remained crucial as her son, now six, grew up with a mix of chronic health concerns, ranging from autism to a brain tumor.

Mullenmeister’s experience of dealing with long-term trauma and navigating additional health concerns is common. Hand to Hold offers ongoing support to families as their kids age via forums and Facebook groups. Hand to Hold also recently launched a podcast series, NICU Now, that explores life in the NICU, with a new series to come (in English and Spanish) for bereaved parents whose babies passed away in the NICU. The organization is also soon releasing a continuing education podcast series for NICU nurses. The podcast has been downloaded more than 15,000 times internationally.

For all the refreshed trauma Kelley felt years ago upon returning to the NICU with her daughter, now she returns to the NICU on new terms, not grieving, but as an ambassador. She sees babies struggle, and it’s still painful to watch. But now Kelley turns her eyes to the parents—to anxious fathers, and to mothers, standing in shock in their hospital-issued gowns as the medical team encircles an impossibly small baby. “I don’t ever want another NICU parent to feel alone like I felt,” Kelley says, and so, she will walk over to them, and offer them her hand.

Among the more practical advice that can be offered to international travelers is wisdom of the bathroom. So let me say, as someone who recently returned from China, that you should be prepared to one, carry your own toilet paper and two, practice your squat.

I do not mean those goofy chairless sits you see at the gym. No, toned glutes will not save you here. I mean the deep squat, where you plop your butt down as far as it can go while staying aloft and balanced on the heels. This position—in contrast to deep squatting on your toes as most Americans naturally attempt instead—is so stable that people in China can hold it for minutes and perhaps even hours ...

... while eating.

Bobby Yip / Reuters

...while smoking.

Reuters

...while waiting for customers.

Petar Kudjundzic / Reuters

...while examining art.

Claro Cortes / Reuters

And, for our purposes, while using the bathroom. Toilets are common in Chinese households now, but public restrooms are still dominated by squat pans, which many Chinese find more hygienic due to the lack of thigh-and-toilet-seat contact. The flat-heeled squat position here is crucial, not only for stability on wet porcelain but also—without getting too anatomical—for proper angling and position. Especially for the ladies. Let’s just say if you stay on your toes, your shoes will get hosed.

(Pro tip: Wearing a slight heel helps.)

Of course, squat toilets are not unique to Asia, nor is the deep-squatting position. But so ubiquitous is the position in Asia and so invisible it is in the West that it’s been dubbed the “Asian squat.” The internet is rife withsuggestionsthatmost Americans cannot squat properly, an idea with which I particularly enjoyed taunting my white American boyfriend.

But is this true? Were my taunts fact-based? How much is this nature or nurture? I figured I first had to understand the physiology of the deep squat.

Luckily, at least one other person on the internet is obsessed with squats as me, and he knows something about physiology. That would be Bryan Ausinheiler, a physical therapist in California who has penned aseriesof blogposts about the deep squat. “The squat is a great model for a multi-segmental movement pattern,” Ausinheiler rattled off at the beginning of our phone call. Uh, what does that mean? “The squat is a triple flexion movement. You’ve got bending at the hips, knees, and ankle, so you have to fold everything up underneath you.” There’s a lot going on.

But the key factor seems to be ankle flexibility. In the words of our editor Ross Andersen, “squatting makes me feel like I might rupture my Achilles.” A 2009 study in Japan found that men who found it impossible to deep squat had particularly inflexible ankles. This is also in part, Ausinheiler says, why kids have no problem squatting. “I measured my daughter’s ankle flexibility when she was one day old,” says Ausinheiler. “She has 70 degrees of ankle dorsiflexion! Normal in the West is like 30.” So humans are born squatters; some of us lose it when we stop trying.

In fact, not everyone who can deep squat is, as Ausinheiler puts it, squatting “well,” with feet close together and toes pointed forward. I grew up in the United States with few occasions to squat, and I fall into this category. (A fact I was painfully aware of in China because I had to place my feet wider than the grooved sides of the squat toilet that kept you from slipping on the wet floor.) The position, while doable, is not particularly comfortable for me either. When an editor dared me to write this entire article while squatting, I quickly realized I’d either end up with an extremely short article or a workplace injury.

Body shape also seems to play a role. Short limbs, big heads, and long torsos make it easier to balance. (Again why toddlers have it so easy.) “I have three brothers, so of course every year I test all their abilities to deep squat,” Ausinheiler told me. “What I found is of the four of us, my squat is the best, I gotta say, but I’m also most conscious of technique. I have another brother who has even shorter legs than me. His squat isn’t quite as good as mine but it is very easy for him. And then the brother with the longest legs has the worst squat. He kind of has a hard time with it.”

Believe it or not, no one appears to have actually studied innate ability in deep squatting across ethnic groups. “You would have to take kids from the time they’re born in China and never let them do any squats to be a control group, and it’ll never happen,” says Matt Hudson, a physiologist at the University of Delaware, who kindly humored my questions. And ultimately, it may not matter. Practice and training make the bigger difference. (I suggested to my boyfriend that he could improve his squats, but he refused for reasons I cannot fathom.)

Reuters / Yves Herman

And Ausinheiler says he has seen more people interested in doing a deep squat—thanks to Crossfit. Weightlifters squat in a deep position, pushing up through the heels. And weightlifting shoes, Hudson points out, usually have a slight heel to help. Crossfit has turned a lot of people into weightlifters—and in turn, made them conscious of their stiff ankles.

There is another group of pro-squatters, those who believe America’s bowel problems can be blamed on toilet seats (the argument has to do with the anorectal angle). Squatting is of course how our ancestors pooped for millennia. Yet this ability that comes so naturally to cavemen and to babies has been lost to many Western toilet sitters—and it’s not so easy to get it back.

With the opioid epidemic claiming more than 100 lives a day in the U.S., every state now has some sort of law expanding access to naloxone, also known as Narcan. Naloxone is an opioid antagonist that makes someone who has overdosed start breathing again. Sometimes, its powers are said to bring an overdose victim “back to life.” That led two economists to wonder, does the prospect of not dying from opioids make people more likely to use opioids? And are they more likely to, ultimately, die as a result?

The two researchers—Jennifer Doleac, of the University of Virginia, and Anita Mukherjee, of the University of Wisconsin—looked at the time period before and after different naloxone-access laws were put into place, such as providing legal immunity to people who prescribed or administered the drug and allowing anyone to buy naloxone in a pharmacy without a prescription.

After naloxone-access laws take effect, they found, arrests related to the possession and sale of opioids went up, as did opioid-related ER visits. Meanwhile—and most worryingly—there was no overall impact on the death rate. In fact, in the Midwest, the implementation of naloxone laws led to a 14 percent increase in opioid-related mortality, they found.

To Doleac, it’s an example of moral hazard. In other words, “anytime you make something less dangerous, people are going to do more of it,” she told me. In one study, for example, giving teens free condoms actually led to an increase in teen pregnancy. In this case, the study purports that heroin users figured they stood a good chance of being revived if they overdosed, so they kept on using.

Doleac announced her findings with a Twitter thread:

My paper on Naloxone access and opioid abuse (joint work with @anita_mukherjee) is now online:

She was not quite “ratioed,” to use the digerati term for a tweet that garners more responses than approvals. But she nevertheless prompted a vigorous online debate that raged for nearly a week. In the white-paper-reading realm, that’s practically World War III.

Public-health people were, perhaps understandably, alarmed by Doleac and Mukherjee’s findings, suggesting they might lead cities and states to pull back from providing naloxone freely. Naloxone access is considered a pillar of “harm reduction,” or the idea that if people can’t immediately be cured of addiction, we should at least make it less dangerous for them to keep using.

As someone working on the front lines with actual overdose patients and drug users, these kind of unfounded claims increase stigma and impede harm reduction. It’s incredibly ridiculous and uninformed to say that ‘naloxone distribution “led to” increased fentanyl use.’

As with almost every study, there are other studies that came to different conclusions. One 2012 study in Massachusetts found that opioid-overdose death rates were reduced in communities where people were given nasal naloxone rescue kits, and another paper last year came to a similar conclusion. One study found naloxone did not lead to increased heroin use.

Leana Wen, Baltimore’s health commissioner and an advocate for the expansion of access to naloxone, pointed out that just because the laws around naloxone changed doesn’t mean people were able to instantly obtain it more easily. “[Doleac and Mukherjee’s] study assumes that passage of these laws lead immediately to everyone having easy access to naloxone when they need it, when this is not the case,” she said. “The Massachusetts study shows that actual naloxone distribution shows decrease in mortality. This is consistent with what we see in Baltimore, where over 1,600 lives have been saved as a result of our naloxone distribution program.”

Wen also said that even though there was no reduction in opioid-related mortality, the death rate might have been even higher without naloxone.

Several critics of the study claimed it is yet another example of the classic problem of confusing correlation with causation. “The first problem is that they seem to be making the big mistake of assuming that correlation equals causation,” said Jermaine Jones, a Columbia University neurobiologist whose study found naloxone didn’t increase heroin use. “This misinterpretation of data is one of the first things we are taught in psychology.” Jones went on to tell me about the classic example of ice-cream sales and murder rates. Of course the sugar high doesn’t spark killing rampages; the hidden variable there is summertime.

But Doleac and other economists say this is one of the differences between public-health research and economics. Economists often make “causal inferences”: They study natural experiments like law changes, use statistical tools to rule out other explanations, and draw conclusions about cause and effect. (Doleac, in turn, criticized the methods used in the studies that came to different conclusions than her own.)

“Public-health people believe things that are not randomized are correlative,” said Craig Garthwaite, a health economist at Northwestern University. “But [economists] have developed tools to make causal claims from non-randomized data.”

This difference of opinion about causality led to exchanges like this one, between one of Doleac’s critics and another female economist, Analisa Packham:

The other thing critics brought up is that Doleac and Mukherjee’s article is not yet peer-reviewed—they plan to submit it to journals soon. But this, too, is an important difference between economics and some other types of health research. Economists tend to put out working papers and circulate them among colleagues long before they submit to journals. For example, Doleac and Mukherjee’s paper thanks several economic conferences and their participants in its acknowledgements. These colleagues—sometimes in pressure-cooker-esque seminars—ask questions and make suggestions, after which the paper is revised, then submitted.

Though this is not quite the same as a journal’s peer review process, it’s not quite a personal Word document uploaded to the internet, either. Because of that, economics working papers are regularly discussed by journalists, academics, and even policymakers before they’re formally published in a journal.

What’s more, the Twitter conversation at times turned unusually venomous and condescending, especially for an economics paper.

In some cases, it seemed more suited to, say, debates about putting peas in guacamole or the potential outcomes of single-payer health care. The tone “felt sort of accusatory and ‘let me explain to you simple authors about how this works,’” Garthwaite said.

One person, for example, called Doleac “a ghoul:”

You are a ghoul who explicitly and in a published paper said saving people's lives is a downside, the Brookings Institute should be razed and the earth salted

All of this isn’t to say that Doleac and Mukherjee’s findings are the last word on the matter, or that they shouldn’t be scrutinized and (respectfully) questioned. They might still hit snags in peer review, or another study might come along and refute their findings. Such is the nature of science.

But it does suggest two things: First, more research is (almost) always good. Doleac told me she tried to replicate an earlier study on naloxone and mortality, and she failed. Maybe someone else might try to replicate her work and fail, too.

Second, when studies come along that find something we don’t like, the instinct can be to flinch and look away—or worse, to insult the study author. But it’s important not to dismiss findings like these, because if they hold up, they might tell us how to better shape public policy.

The other famous example of moral hazard involves car-safety regulations: Safer cars make people drive more recklessly, according to an infamous 1970s study. But, Garthwaite told me, “no one who’s serious would say that just because moral hazard exists means we shouldn’t put seat belts in cars.” In this case, it might mean that cities should dispense naloxone, but that they should also invest more in treatment—something Doleac and Mukherjee themselves call for in this study. Naloxone, Garthwaite said, might be a good intervention, but it might not be a good intervention on its own.

Doleac said this was the last round of comments she was hoping to get before she submits to peer review. “...And we have gotten it,” she added, in the form of the hundreds of tweets and emails.

Doleac is no stranger to controversy. Previously, she studied racism and gun violence. “The response to this has been so much more negative and hostile than anything else I’ve worked on,” she said. She said one doctor emailed her to explain how to write an academic paper. “I was like, ‘I’ve actually done this before!’”

She also said she hasn’t heard anything that would change the overall conclusions of the study. “We might clarify some things in the text,” but those changes, she acknowledges, “probably won’t make anyone happy.”

A new paper confirms what many Americans likely suspected: A mass economic downturn—on the scale that occurred during the Great Recession—makes people physically sick.

Past research has been surprisingly mixed on the effect of economic downturns on physical health. A review paper published in 2016 found that though alcohol use and traffic fatalities declined during the Great Recession, overall, people had fewer babies, had worse mental health, and were more likely to kill themselves. But other papers have found that death rates actually decline during recessions, as Neal Emery wrote for The Atlantic in 2012. Cubans got healthier during the early-90s economic crisis.

These counterintuitive findings led the economist Tyler Cowen, in the New York Times in 2009, to extoll economic hardship as some sort of hot new workout plan:

In the United States and other affluent countries, physical health seems to improve, on average, during a downturn. Sure, it’s stressful to miss a paycheck, but eliminating the stresses of a job may have some beneficial effects. Perhaps more important, people may take fewer car trips, thus lowering the risk of accidents, and spend less on alcohol and tobacco. They also have more time for exercise and sleep, and tend to choose home cooking over fast food.

For the study, Teresa Seeman, an epidemiologist at the University of California, Los Angeles, and her colleagues examined longitudinal data on 4,600 people between the ages of 45 and 84 collected between 2000 and 2012 to look for changes in their blood pressure and fasting blood-sugar levels.

They found that blood pressure increased significantly among all groups during the time period, and blood glucose did too, among certain groups. The authors speculate the reason for the spike was stress—potentially different stressors for different generations. The younger people in the cohort were either unemployed, or those still working were likely wondering how on Earth they would be able to retire. The older people may have owned their own homes and watched the housing market collapse. All of this, they found, likely drove up their stress levels, and blood pressure.

The authors also found that during the recession, many people stopped taking their medications—especially older homeowners, whose major sources of wealth were evaporating. “The evidence suggests that the stresses of the Great Recession took their greatest toll on those who are on medication,” they write—because they may not have been able to afford the drugs anymore.

These findings further confirm what other researchers have seen on a more cellular level: Economic hardship causes stress, and that stress can sneak under the skin, disrupting bodily systems. Of course, that stress can come from other sources, too—like, for example, an unusually distressing news cycle lurching from one scandal to another.

“It will be interesting to see what the effect will be of all the upheaval we're going through now,” Seeman told the Washington Post, ominously.

It’s a rare person who goes out of their way to spend time with psychopaths, and a rarer one still who repeatedly calls a prison to do so. But after more than a year of meetings and negotiation, Arielle Baskin-Sommers from Yale University finally persuaded a maximum-security prison in Connecticut to let her work with their inmates, and to study those with psychopathic tendencies.

Psychopaths, by definition, have problems understanding the emotions of other people, which partly explains why they are so selfish, why they so callously disregard the welfare of others, and why they commit violent crimes at up to three times the rate of other people.

But curiously, they seem to have no difficulty in understanding what other people think, want, or believe—the skill variously known as perspective-taking, mentalizing, or theory of mind. “Their behavior seems to suggest that they don’t consider the thoughts of others,” says Baskin-Sommers, but their performance on experiments suggests otherwise. When they hear a story and are asked to explicitly say what a character is thinking, they can.

On the face of it, this makes sense: Here are people who can understand what their victims are thinking but just don’t care. Hence their actions. But Baskin-Sommers found that there’s more to their minds than it seems.

Most of us mentalize automatically. From infancy, other minds involuntarily seep into our own. The same thing, apparently, happens less strongly in psychopaths. By studying the Connecticut inmates, Baskin-Sommers and her colleagues, Lindsey Drayton and Laurie Santos, showed that these people can deliberately take another person’s perspective, but on average, they don’t automatically do so to the extent that most other people do. “This is the first time we’re seeing evidence that psychopaths don’t have this automatic ability that most of us have,” Baskin-Sommers says.

She started studying psychopaths around ten years ago, “before the time when ‘psychopath’ was a term used in every TV show,” she says. “I’ve become fascinated with how complex their minds are. They rarely show a complete deficit in things. There’s interesting nuance. Sometimes, they seem to show good cognition, sometimes they don’t. Sometimes they show theory of mind, and sometimes they don’t. That’s an interesting puzzle.”

The U.S. prison system doesn’t assess psychopathy at intake, so Baskin-Sommers administered a standard test herself to 106 male inmates from the Connecticut prison. Of them, 22 proved to be psychopaths, 28 were not, and the rest fell in a gray zone. Baskin-Sommers did all the interviews in a makeshift psychology lab within the prison itself—a simple room with a desk, computer station, and no barriers.

“There’s security, but it’s outside because what we do is confidential,” she says. “We do a lot of training and we’re always sitting closer to the door. But we’ve never had an incident, or come close. For many of the inmates, it’s the first time anyone even asked them to talk about their lives.” The psychopaths proved to be “glib, narcissistic, and conniving,” she adds. “They can be aggressive, and they like to tell us gruesome details of murders, I think to shock us. But it’s not like that all the time. They do a lot of impression management.”

After assessing the 106 volunteers, she then gave them a computer-based task. They saw a picture of a human avatar in prison khakis, standing in a room, and facing either right or left. There were either two red dots on the wall in front of the avatar, or one dot in front of them and one dot behind them. Their job was to verify how many dots either they or the avatar could see.

Normally, people can accurately say how many dots the avatar sees, but they’re slower if there are dots behind the avatar. That’s because what they see (two dots) interferes with their ability to see through the avatar’s eyes (one dot). This is called egocentric interference. But they’re also slower to say how many dots they can see if that number differs from the avatar’s count. This shows how readily humans take other perspectives: Volunteers are automatically affected by the avatar’s perspective, even when it hurts their own performance. This is called altercentric interference.

Baskin-Sommers found that the psychopathic inmates showed the usual level of egocentric interference—that is, their own perspective was muscling in on the avatar’s. But they showed much less altercentric interference than the other inmates—the avatar’s perspective wasn’t messing with their own, as it would for most other people.

Of course, not all psychopaths are the same, and they vary considerably in their behavior. But Baskin-Sommers also found that the higher their score on the psychopathy assessment test, the less they were affected by what the avatar saw. And the less affected they were, the more assault charges they had on their record.

Psychopaths may be conniving, but it’s unlikely that they could have deliberately gamed the task to engineer interesting results. “The task is too fast, and we see no differences in accuracy between them and others lower in psychopathy,” Baskin-Sommers says.

To her, the results show that psychopaths (or male ones, at least) do not automatically take the perspective of other people. What is involuntary to most people is a deliberate choice to them, something they can actively switch on if it helps them to achieve their goals, and ignore in other situations. That helps to explain why they behave so callously, cruelly, and even violently.

But Uta Frith, a psychologist at University College London, notes that there’s some controversy about the avatar task, which has been used in other studies. “What does it actually measure?” she says. It’s possible that the avatar is acting less as a person and more as an arrow—a visual cue that directs attention. Perhaps instead of perspective-taking, the task simply measures how spontaneously people shift their attention.

Baskin-Sommers argues that the task is about both attention and perspective-taking, and “for research on psychopathy, that is a good thing.” That’s because, as she and others have shown, psychopaths pay unusually close attention to things that are relevant to their goal, but largely ignore peripheral information. “It’s like they’re the worst multitaskers,” Baskin-Sommers says. “Everyone’s bad at multitasking but they’re really bad.” So, it’s possible that their lack of automatic perspective-taking is just another manifestation of this attentional difference. The two things are related.

Other groups of people also show differences in their theory of mind. For example, in one study, Frith asked people to predict where a girl might search for a marble that had been moved without her knowledge. The onlookers knew the marble’s whereabouts, so could they override their own knowledge to step into the girl’s shoes? Eye-tracking software revealed that neurotypical adults look at the same place the girl would, but people with Asperger’s syndrome are less likely to. They don’t seem to spontaneously anticipate others’ actions. “It is a bit worrying if [Baskin-Sommers and her colleagues] are proposing the very same underlying mechanism to explain callousness in psychopathy that we used previously to explain communication problems in autism, albeit based on a different test,” Frith says. “These are very different conditions, after all.”

But there are subtle and important differences between the two studies, Baskin-Sommers says. Frith’s task didn’t look at whether another person’s perspective affects your own—and that’s what differs in psychopaths. They can take the perspectives of other people, but those perspectives don’t automatically impinge on their own. “This isn’t the typical pattern shown when identifying theory of mind deficits,” she says.

These new findings do not “explain” psychopathy; no single study would. Like most psychiatric problems, it’s a complex mess of genetic and environmental influences, all impinging on our most complex (and perhaps least understood) organ—the brain. Psychopaths may show a lack of automatic perspective-taking, but “the interesting question is: Why?” says Essi Viding from University College London. “What in the genetic makeup and rearing environment of a person makes them like that? We need [long-term studies] to answer these questions and to investigate how malleable these processes are.”

Meanwhile, Baskin-Sommers adds that there are ways of using what we already know. “We’re thinking about training prison officers in how to talk to inmates with psychopathy, and force a more deliberate perspective-taking,” she says. After altercations within the prison, “it’s normal to say ‘You did something wrong’, or ‘What happened here?’ These data suggest that psychopaths won’t be able to answer that question. Unless you force them to take another inmate’s perspective on what happened, they won’t understand.”

BAKERSFIELD, Calif.—The police report is all David Cole Lang’s family has to describe his last moments on Earth.

Fifty pages of officer narratives and witness interviews filled with grisly detail, it lacks any explanation for his death. Many months later, Lang’s widow, Monique, says she still has no clue as to why the 33-year-old combat veteran and father who struggled with opioid addiction ended up fatally shot by a doctor whom—as far as Monique knew—he hadn’t seen in over a year.

“I didn’t understand why he was there,” she says. “I still don’t.”

On that April evening last year, according to interviews in the report, Lang yelled and cussed at the addiction- and pain-treatment doctor, Edwin Zong, in his office, and leaped across a desk to punch him repeatedly. Hearing the doctor scream for help, the last patient waiting to see Zong that day ran to open the door. He told police he found Lang standing over Zong, curled in a fetal position on the floor, his face covered in blood and “the fear of a child in his eyes.”

“Hey!” the patient yelled.

When Lang turned toward the doorway, Zong told police, the doctor opened a desk drawer and grabbed a handgun. He fired three or four times. One bullet tore through the blood vessels in Lang’s neck. He staggered outside, collapsed in a parking lot, and died.

Local authorities concluded that Zong had acted in self-defense and he faced no charges. In an email to Kaiser Health News, the doctor declined a request for an interview but said he believes he was targeted for robbery. “I was lucky I wasn’t killed,” he wrote. “Treating addiction is a very tough job, many doctors won’t do it.”

The tragedy that played out in Zong’s office speaks to a dangerous trend: In many parts of the United States, the number of people addicted to opioids far exceeds the capacity of doctors willing and authorized to treat them. That is particularly true when it comes to professionals like Zong who dispense Suboxone or Subutex, both formulations of buprenorphine, which is widely considered the optimal addiction treatment because it all but erases opioid-withdrawal symptoms without creating a significant high.

David Cole Lang was shot to death on April 25, 2017, after he attacked a doctor he once saw for opioid-addiction treatment, according to police records. (Brian Rinker / Kaiser Health News)

One reason for the shortage of providers is that doctors must take eight hours of training to prescribe the medication and apply for a waiver from the Drug Enforcement Administration, because the medicine is itself an opioid. Few doctors are willing to check all those boxes and take on the sometimes difficult patients who seek the drug. Access remains a huge obstacle, even as the Food and Drug Administration is seeking to broaden the medications available for opioid treatment.

Patients addicted to heroin or prescription opiates like oxycodone or fentanyl suffer severe withdrawal—sweats, tremors, anxiety—and are often desperate for medication-based treatment to wean them from the drugs or at least quell their symptoms. For the cash-strapped patients, the cheaper the better.

Doctors who accept these patients, whether motivated by profit or compassion, can become overwhelmed, seeing far more than their offices can handle, opening the door to chaos and lawlessness. More problematic, some clinics, like Zong’s, offer a mix of services—treatment for both opiate addiction and pain. Patients being prescribed potentially dangerous narcotics are mixed in the waiting area with those struggling to kick addiction.

Several years ago in Vermont, which pioneered buprenorphine treatment, some small practices rapidly swelled to 600 or 700 patients each, says Richard Rawson, an experienced addiction researcher at the University of Vermont. Doctors sometimes prescribed more than their authorized limit, failed to test patients for drug abuse, and—wittingly or not—fostered illegal sales, Rawson says.

“We know that when you have those types of practices where you bring large numbers of addicted individuals together it produces a mess,” he says. “People are selling drugs in the parking lot and all kinds of wacky stuff like that.”

Inevitably, some patients relapse. Some become angry if they don’t get what they came for. A solo practitioner like Zong—who, by many accounts, had few employees, a tendency to work late on his own, and a high cash intake—faces security risks.

Zong was concerned enough to stow a gun in his desk drawer. “I keep a gun in my office for self-protection,” he said in his email.

In California, demand for buprenorphine has only grown with the opioid epidemic and recent changes to Medi-Cal, the state’s Medicaid program, which have made it easier and quicker for low-income people to get the drug. The program was expanded under the Affordable Care Act to cover more adults (3.8 million) and more drug treatment.

In addition, beginning in June 2015, doctors were no longer required to get prior approval from the Medicaid program each time they prescribed buprenorphine.

Within seven months, claims jumped 100 percent, according to the state.

Zong, an osteopathic physician who had trained in internal medicine in New York, opened his Bakersfield practice in 2007. Situated next to a marijuana dispensary, it was a one-stop shop for pain management, addiction treatment, and acupuncture. Though Zong’s medical training didn’t focus on those areas, he had the necessary DEA waiver to prescribe buprenorphine by 2010, records show.

Zong had a reputation for writing scripts cheap and fast, according to numerous interviews with former patients, drug-treatment professionals, and pharmacy employees in the area. Lines of sometimes agitated patients stretched from the waiting room into the parking lot, the street, and the dirt lot across the road, patients and neighbors say.

If the wait was lengthy, the appointments weren’t, the patients say.

“When I walked in the first time,” says Brian Adams, a former patient, “[Zong] said, ‘What’s going on?’ I said, ‘I’m a heroin addict. I need help.’ He said, ‘Okay, I’ll write you a prescription for Suboxone.’”

No intake. No drug testing. No counseling. “I was in and out in five minutes,” Adams says.

The price for the visits ranged from $80 to $100 cash to secure the medicine, patients say—far cheaper than anywhere nearby.

There was an option like that within a few miles of Zong’s office: Aegis Treatment Centers, which runs opioid-treatment clinics closely regulated by the government. The clinics require services including intake, urine testing, and counseling for opioid treatment.

From a hard-up patient’s perspective, Aegis had another downside: It had not yet been approved to accept Medi-Cal for buprenorphine, which was dispensed on site as take-home pills. The range of services and medication cost nearly $700 per month for patients without insurance, with a limited number of discounts available to poorer patients.

Zong’s Medi-Cal patients had it easier: Their freshly issued scripts were covered at local pharmacies.

Zong had good reasons to be concerned about security. He’d had a handful of break-ins at the clinic, his vehicle, and his home—one recently, according to the police report.

At some point, Zong became licensed to carry and conceal a firearm. Adams says he once saw him pull it out when Adams got confrontational.

Angry that Zong wouldn’t prescribe him an antianxiety medication, “I stood up and was like, ‘Man, fuck you,’” Adams says. Zong pulled his gun out and placed it on the table in front of him, Adams says, and he quickly sat back down.

Patients and pharmacists say Zong sometimes added addictive antianxiety drugs like Xanax to buprenorphine prescriptions for people presumably seeking to escape addiction. Besides creating the potential for further drug abuse, the combination can be deadly, experts say.

A prescription written by Edwin Zong for Subutex (an opioid) and Xanax (an antianxiety medication) is on file at a Walgreen’s pharmacy. Generally, experts say such drugs should not be taken together because they can suppress respiration. (Brian Rinker / Kaiser Health News)

Records of Medi-Cal claims obtained by Kaiser Health News show that, in addition to treating patients with buprenorphine, Zong prescribed significant amounts of highly addictive opioids, including oxycodone and hydrocodone, as well as habit-forming antianxiety medications. They do not show what combinations of drugs were offered to each patient.

Staffers at three pharmacies in the area say they were concerned about peculiarities in Zong’s prescriptions or drug-seeking behavior among his patients.

Chang adds that Zong’s scripts sometimes included a potentially dangerous cocktail of sleeping pills, narcotics, and antianxiety medications. He showed a reporter one of Zong’s 2013 prescriptions for Subutex and Xanax.

“We just stopped taking his scripts,” Chang says.

After the killing, police found a ski mask, a black hoodie, and a recently used meth pipe in Lang’s car, according to their report. Witnesses reported to police that Lang came into the offices saying “something about money” or that he was “waiting on his money.”

Court records show Lang pleaded no contest for misdemeanor burglary in 2014 and served three days in jail.

Lang’s family is skeptical that Lang was trying to rob Zong. They acknowledge, however, that he was not the man he used to be.

When Monique met Cole, as he was called, she was still in high school. He was an outgoing and funny 19-year-old, with beautiful green eyes and a sharp wit. In short order, they married and he shipped out to Iraq. Then came two more tours, in Iraq and Afghanistan. One explosion, then another, nearly killed him.

When he came home to his wife and baby daughter, he “was a lot different, especially around family functions,” says Monique Lang. He wouldn’t want to go, and if he did, he was quiet and remote. “I was like, ‘This isn’t you. What is going on?’ He never would say.”

In 2009, after Monique discovered money missing from the couple’s bank account, her husband came clean: He was hooked on opioids. From then on, it was a roller coaster of pills, heroin, and rehab. In the middle of it all, they had a son, now 4.

Lang’s family says the former Marine was in constant pain, physically and mentally. He had a severe back injury. He screamed in his sleep. His daughter, now 10, would sleep on the couch downstairs to escape the sound.

David Cole Lang served in the Marine Corps, with two tours in Iraq and one in Afghanistan. After his return home, he suffered chronic pain, night terrors, and symptoms of post-traumatic stress disorder. (Brian Rinker / Kaiser Health News)

He secretly wrote suicide notes to his wife and kids.

Zong told reporters the day after the shooting that he did not remember seeing Lang before. But the family told police he was seen on occasion between 2012 and 2015, according to their report, and that he received Suboxone for opioid addiction.

In an interview, Monique Lang said she once accompanied Cole to an appointment. She didn’t like the atmosphere, she said, and didn’t understand how taking a medication with no other services would help her husband.

But that was history—or so the family thought. By last April, they believed Lang was sober, getting the support he needed at Aegis.

Zong told police he performed one final task on his clinic’s last day, with Cole Lang dying outside on the asphalt and squad cars en route: He wiped the blood from his battered face and agreed to write his remaining patient a prescription.

In the skin-care aisle at the CVS pharmacy closest to my office, there are 106 different products for acne. I lurked in the store for an hour last week tallying anything with the words “acne,” “blemish,” or “blackhead” on the packaging. I did not include products labeled “pore refining,” because that seems fake.

There are 101 antiaging products on the shelves. This includes anything that claims to fight wrinkles, or that is labeled “antiaging” or “age defying.” I did not count the following terms: “age perfect,” “lifting,” “for sagging skin,” or “for mature skin,” even though those were clearly meant to evoke antiaging effects without explicitly saying so.

There were 155 types of body lotion and 177 types of face lotion, although in certain cases it was hard to tell which category a particular product would fall under. I included anything called a “lotion,” “moisturizer,” “cream,” “gel,” “gel-cream,” “cream-gel,” “moisturizing oil,” “salve,” “hydrating mist,” “intense-hydration concentrate,” and in one case—may God have mercy on my soul— “daily liquid care.” I did not tally “cream cleansers,” “serums,” “treatments,” “fillers,” or “elixirs.”

These are just some of the over-the-counter skin-care products available at one drugstore. We haven’t even gotten into cleansers, let alone masks or scrubs or toners. Suffice it to say, figuring out what skin-care products to use can be daunting.

The skin-care industry uniquely straddles the line between health and aesthetics, between drugs and cosmetics. Acne and other skin conditions often require medical treatment and prescription drugs, yet it’s possible to treat some breakouts, or dryness, or redness, at home. Sometimes there may be nothing wrong, per se, but one’s skin could always be a little more even, a little softer, a little glowier, couldn’t it? There’s also a certain amount of care needed to maintain the status quo—to stay clean, moisturized, and protected from the sun.

All of these pursuits fall under the umbrella of “skin care.” The industry does little to help anyone make sense of it. In fact, it is often deliberately confusing.

A few common skin-care ingredients are regulated as drugs. These include those in sunscreen; salicylic acid and benzoyl peroxide, which are used to treat acne; and adapalene, the main ingredient in the newly over-the-counter product Differin. Many more are not. The Food and Drug Administration defines “drugs” as:

Articles intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease. ... [And] articles (other than food) intended to affect the structure or any function of the body of man or other animals.

It defines “cosmetics” as:

Articles intended to be rubbed, poured, sprinkled, or sprayed on, introduced into, or otherwise applied to the human body ... for cleansing, beautifying, promoting attractiveness, or altering the appearance.

When does “altering the appearance” cross over into “affecting the structure or function of the body?” Skin-care companies are very careful in their phrasing to stay on the less burdensome cosmetic side of that line. Many of the antiaging products on the CVS shelves claim to “diminish the look of fine lines and wrinkles” (emphasis mine). Commercials throw out statistics like 90 percent of women saw improvements in the skin after just one use of product X, Y, or Z. But “wrinkles do look better when you hydrate the skin,” says Tiffany Cukrowski, a dermatologist at the Midwest Center for Dermatology and Cosmetic Surgery. “So it has a moisturizing effect, not a true antiaging effect.”

Cosmetics are innocent until proven guilty. Their ingredients don’t have to be proven safe, or effective. Even if a particular ingredient has some evidence behind it, cosmetic manufacturers aren’t required to prove that the ingredient works in that product’s specific formulation, or at that particular concentration. Often, the only way to figure out if something works is to try it.

The skin-care landscape is vast, overwhelming, and shimmering with mirages. But more and more people are trying to navigate it. The skin-care market is projected only to keep growing in the next couple years, according to data from Euromonitor, a market-research provider. “Everybody’s obsessed with skin care right now,” Ashley Weatherford writes in the The Cut.

In The Outline, Krithika Varagur writes that “perfect skin has become the thinking woman’s quest.” She goes on to say that skin care is a consumerist scam, but she’s touched on something with her emphasis on “thinking.” Confronted with the multitudinous choices and absent good information about the efficacy of different products, many skin-care fans have become citizen scientists—educating themselves and each other about what works and experimenting on their own faces.

“For most of my life I wasn’t too serious about skin care. I’d use random drugstore products that I was drawn to on a purely superficial level,” the beauty writer Rio Viera-Newton told me in an email. “Only after college, when, for various medical reasons, I went off birth control and started having really aggressive, painful breakouts, did I decide I wanted to create a routine for myself. I was initially really overwhelmed by all the information and advice out there on the internet. I read just about every article on hormonal acne and would binge-watch ‘How I Cured My Hormonal Acne’ YouTube videos for hours.”

Viera-Newton eventually got it figured out—partly by consulting a dermatologist, and partly by narrowing down her online searches to recommendations from people who shared her dry, sensitive skin type. She built up a routine, and is now dispensing skin-care advice for The Strategist. A post she wrote in the summer of 2017, “The Google Doc I Send to People Who Ask About My Skin,” details her elaborate skin regimen. It was so widely shared that one of the autocorrect options when I Google her name is “Rio Viera-Newton google doc.”

Framing the article as Viera-Newton’s advice to her friends was savvy. Because there are so many products out there, and because there are so many good reasons to be skeptical of brands’ claims about them, word of mouth often feels like the most trustworthy resource for information on over-the-counter skin care. People often turn to their friends—or their favorite beauty bloggers—to find out what really works. (Dermatologists, of course, are the best resource, but if you don’t have a medical reason to see one, you’re not likely to pop in and ask if you should be using Noxzema or Neutrogena face wash.)

My own skin-care routine is cobbled together with prescriptions from my dermatologist alongside recommendations from coworkers at bars, from the beauty writer Arabelle Sicardi, from the private makeup and skin-care Slack channel I share with my friends (called “People With Faces”), and from the subreddit r/SkincareAddiction.

This forum is the most visible repository of the apparently growing interest in the science of skin care. It has more than 450,000 readers, and the growth curve of its subscriber base has notably steepened since mid-2017. Its posts are a mix of memes, users seeking advice, product reviews, before-and-after skin selfies, and “shelfies”—pictures of users’ bathroom shelves crowded with products. But it also has an exceptionally well-organized reference section, summarizing the conclusions of the hive mind on ingredients, the identification and treatment of certain skin conditions, the best products, and how to build an effective routine with them. Many posts refer to scientific papers in their explanations.

The core of the subreddit’s advice boils down to a routine of two to five steps: Cleansing and moisturizing, with the “optional” additions of exfoliating (chemical exfoliators are preferable to scrubs), spot-treating blemishes, and sunscreen (“optional but highly recommended”). It has product recommendations for each of those categories (the community crowdsources its “Holy Grail” recommendations), and there are further rabbit holes to burrow into if you want to get into antiaging or specialty serums or whatnot.

“The advice was definitely decent,” Cukrowski, the dermatologist, says of the subreddit. “Especially the part where they talked about whether you need a toner or not. I always tell my patients you don’t need a toner unless you’re really oily.”

Michelle Wong is a moderator at r/SkincareAddiction, and a high-school science teacher in Sydney, Australia, with a chemistry Ph.D. She says that “on the whole, [r/SkincareAddiction] is probably one of the most scientifically accurate sources. Where they get it wrong is mostly in the details and the really nitty-gritty. But if you follow the advice on there, it will be maybe 90 percent the same as a completely accurate regime.”

“When I started my blog I didn’t think I would get any sort of audience, but it’s gotten quite big,” she says. “A lot of people tell me, ‘I hated science, but this is really interesting. If it’d been taught like this in school, I would’ve been really interested in chemistry.’ So people are getting more educated about how things work.”

Dana Sachs, a dermatologist at the University of Michigan, says she’s seen her patients “come in and ask more pointed questions about different products than they used to.”

Some skin-care brands are catching on to this savvy consumer base. In late 2016, the beauty company DECEIM launched its brand The Ordinary, a line of simply packaged serums labeled with just their active ingredients and concentrations. You can buy “Retinol 0.2 percent in Squalane,” or “Magnesium Ascorbyl Phosphate 10 percent,” or “Niacinimide 10 percent + Zinc 1 percent”—not exactly the catchiest-sounding products. But according to DECEIM’s former co-CEO, Nicola Kilner (who has left the company under bizarre circumstances since our interview), The Ordinary is the company’s biggest brand, and sold 8 million units in its first year. She attributes this to the brand being “led by consumers.”

The Ordinary started listing the pH of its products as a result of customers clamoring for that information, Kilner says. And in the closed Facebook group “The Ordinary and DECEIM Chat Room,” which has nearly 32,000 members, she says the discussions can get pretty scientific, with users sharing spreadsheets of their routines and talking about ingredient interactions.

“We’re led by the fact that they do have this appetite,” Kilner says. “They do want to learn. They no longer want to just believe in hocus-pocus potions. They want to actually understand what ingredients they’re using at what percentage.”

Unfortunately, this desire for understanding can quickly run up against a wall. Academic studies are often inaccessible to the public. And even though there is some good research on skin care out there, it’s understandably skewed toward prescription drugs and the treatment of medical skin conditions like acne and eczema.

“My background is in medicinal chemistry, so I’m used to saying if [a study] is under 100 subjects, then it’s not worth looking at,” Wong says. “But in skin care, if it has more than 10 subjects, it’s amazing, because there’s just not funding. Because it’s not regulated as drugs.”

For ingredients that do have evidence behind them, there are often caveats and unknowns that remain.

Take the chemical compounds known as retinoids. “There is really good evidence behind topical retinoids exerting a positive antiaging benefit in skin,” Sachs says. They increase skin’s collagen production, and can combat hyperpigmentation.” Prescription retinoids like tretinoin are a mainstay of dermatological antiaging treatment. But the form found in over-the-counter products—retinol—is what is known as a prodrug, meaning it doesn’t convert into the active form of retinoic acid until it’s in the body. Some studies have found retinol to be an effective antiaging treatment, though far less potent than tretinoin (and less irritating). But retinol is “extremely unstable and easily gets degraded to biologically inactive forms on exposure to light and air,” as one meta-analysis put it.

With an over-the-counter product, “you don’t necessarily know how much of it you’re getting, or how active the ingredient is,” Sachs says. “Not that we know what the right concentration is.” Even the most dogged amateur skin-care scientist won’t be able to figure out what research doesn’t yet know, or what information is hidden by manufacturers.

Another issue with many topical skin products, Sachs says, is that “they have to penetrate the very strong stratum corneum, which is the top layer of the skin.” The skin is a barrier, after all, designed to keep things out. With cosmetics that aren’t tested, there’s no way to know if the molecules penetrate deep enough into the skin to have any effect.

One popular group of ingredients that Sachs and Cukrowski are both skeptical of is peptides. Peptides are chains of amino acids, often included in antiaging serums and creams, with the thought that they might stimulate collagen production. “But one of the issues with peptides—that I don’t know the answer to—is they tend to be huge molecules that don’t necessarily penetrate into the skin,” Sachs says.

“The peptides are a big scam,” Cukrowski says.

Indeed, skin care, like any trend, has seen its share of backlash. In her Outline article, “The Skincare Con,” Varagur questioned the purpose of the entire industry: “All of this is a scam. It has to be. ... Most skin care is really just a waste of money.” There certainly are ample opportunities to waste one’s money on insanely pricey serums and lotions.

But just because there are some dubious claims floating around doesn’t mean we should throw our baby-smooth skin out with the bathwater. There are also things like sunscreen, and acne medication, and moisturizer, that are uncontroversially effective.

“As we get older, skin gets thinner, it gets drier,” Sachs says. “The barrier is not as good as it used to be. Whenever there are breaks in the barrier, that’s when you are more prone to infection, that can lead to inflammation in the skin. Moisturizing the skin is really key to keeping it in good shape. Now does the type of moisturizer matter? I don’t know the answer to that.”

What that leaves you with, in many cases, is anecdotal evidence, and trial and error-ing products on your own face.

“Obviously the problem with that is you have one face, so it’s like an n=1 trial,” Wong says. “You don’t know if the product works or if it was sunny that week, so you got more sun, or you started exercising that week as well.”

There’s an element of trial and error in medical dermatology, too. People have different skin types, and some are more irritated by certain ingredients than others. “It’s not like shooting in the dark,” Sachs says. But “that’s the art of medicine. It’s not going to be a one-size-fits-all for every person who comes in, otherwise, we wouldn’t spend as long training as we do. There are not cookbook recommendations for all the things out there.”

Of course, any would-be citizen skin-care scientists should practice lab safety. It’s possible to overdo it and injure yourself with harsh scrubs or exfoliating acids, or to have a bad reaction to an ingredient that you didn’t patch test before rubbing it all over your face. And despite the popularity of 10-step Korean skin-care regimens, there’s also a threshold past which adding more products to your routine isn’t likely to yield additional results.

“You really just need a sunscreen, a cleanser, and a moisturizer,” Wong says. “On top of that, if your skin isn’t already quite good, then you might need an antiaging or anti-acne product. But once you have the right products, a lot of it is just fiddling, [getting] decreasing marginal returns.”

The skin-care craze is sometimes derided as just another unattainable beauty standard—now women are supposed to look flawless without makeup?—to which others respond that it’s a form of self-care. A ritual, a devotional. It can be all of those things. But it’s also an at-home science project, one with results you can see in the mirror.

On Tuesday, 23andMe announced it will start telling customers of its mail-in DNA-testing kit about three mutations in the breast-cancer genes BRCA1 and BRCA2—a move officially sanctioned by the Food and Drug Administration.

“My first thought is: We’re not in 2013 anymore, Toto,” says Misha Angrist, an associate professor at Duke University, who has followed 23andMe’s troubles with the FDA. In 2013, the agency essentially forced 23andMe to suspend all of its health-risk reports, which included BRCA at the time. The FDA’s warning letter—a truly blistering one by bureaucratic standards—specifically warned that women might get mastectomies based on inaccurate BRCA tests.

Since then, 23andMe has been getting back into the FDA’s good graces. The company got FDA authorization on tests for Bloom syndrome in 2015 and risk reports for several conditions such as Parkinson’s and Alzheimer’s in 2017—all of which can be ordered without a doctor’s note.

But the BRCA genes have always been the big one because of how dramatically its mutations increase cancer risk. Women with certain variants have a 45 to 85 percent chance of developing breast cancer and a 44 percent chance of developing ovarian cancer. Angelina Jolie famously documented her double mastectomy in The New York Times after testing positive for a BRCA mutation.

“It’s been a top priority now for years,” Anne Wojcicki, the CEO of 23andMe, says of BRCA. In fact, the company has had the technical ability to test for these mutations this whole time. After 23andMe stopped offering risk assessments following the FDA smackdown, determined customers could still comb through their raw 23andMe data to analyze BRCA mutations. Now, 23andMe is bringing back its own BRCA risk assessments for past customers as well. Wojcicki noted that current clinical guidelines only recommend testing if people have family histories of certain cancers, but 23andMe has found that many BRCA carriers don’t have documented family histories. The pool of women tested for BRCA will likely expand.

23andMe only tests for two mutations in BRCA1 and one in BRCA2, all of which are most prevalent in the Ashkenazi Jewish population. These mutations are among the most common and best studied, but they still account for only a small fraction of hereditary breast cancers in the United States. There are over a thousand known BRCA mutations—some of which are linked to increased cancer risk, some which aren’t, others whose risk is unknown. Historically, some groups, like black women, have been less represented in genetic studies than others. “The group that is significantly under-tested and underserved by genetic testing [is] women of color,” Erika Stallings, who has written about her own experience with BRCA, pointed out in an email.

A negative result for the three mutations highlighted by 23andMe is not, therefore, a negative result for all BRCA mutations. 23andMe has crafted a set of slides to educate customers on this distinction, though it will not offer genetic counseling directly.

Screenshots of a preliminary educational module 23andMe has developed to explain its BRCA results (Courtesy of 23andMe)

Several other companies do offer more complete BRCA tests, which are ordered through doctors and much more expensive without insurance than 23andMe’s $199 home kit. “[23andMe] is not an inexpensive way to get your testing done more cheaply,” says Laura Hercher, a genetic counselor who teaches at Sarah Lawrence College.

23andMe encourages customers who do test positive to contact a doctor for retesting in a clinical lab. Hercher warns this process may also not be so seamless. “If you show up at your doctor’s office with your 23andMe result printout, nine times out of 10, it isn’t going to be, ‘Oh, thank goodness, you brought it to my attention.’ You get a lot of skepticism,” says Hercher. That may change with the FDA’s new stamp of approval on BRCA, she says, as the gene is so well recognized in the medical community—but getting insurance to reimburse for extra screenings initiated by a 23andMe test could be a struggle at first. Right now, insurance companies are only required to cover BRCA screening under certain criteria, often a family history of breast cancer. (23andMe told me it plans to reach out to the reimbursement community on BRCA, and it has not encountered this problem with other health tests it offers.)

In any case, direct-to-consumer testing is clearly knocking on the door of the old medical system. Starting today, 23andMe is offering BRCA results to anyone willing to spit in a kit—now with the government’s official blessing.

The Assyrians treated the “hard-pulse disease” with leeches. The Roman scholar Cornelius Celsus recommended bleeding, and the ancient Greeks cupped the spine to draw out animal spirits.

Centuries later, heart disease remains America’s number one killer, even though medical advances have made it so that many more people can survive heart attacks. Some parts of the country are especially hard-hit: In areas of Appalachia, more people are dying of heart disease now than were in 1980.

Haider Warraich, a fellow in cardiovascular medicine at the Duke University Medical Center (and an occasional Atlantic contributor), is at work on a book about how heart disease came to be such a big threat to humanity. We recently spoke about some of the insights he’s come across in his research and practice. An edited transcript of the conversation follows.

Olga Khazan: So, you say evolution is the main reason you see a lot of heart disease in humans. Why is that?

Haider Warraich: If you look back and see what it was that has threatened human beings for more than 95 percent of our existence, it’s been three main things: infections, injuries or wounds, and malnutrition. In that setting, the most successful human being was the one who had the most paranoid and xenophobic immune system, which would detect any outside activity and then try to destroy it as soon as possible.

Now, that of course, has changed. We don’t have the burden of infections, especially in higher-income countries, but what has happened is that we have been self-selected to have a very, very robust immune system.

For most of human history, things like being bitten by some wild animal or having any type of traumatic injury has been a part of routine human life. The way that we’ve always combated that has been with inflammation. When the immune system is activated, it results in inflammation. For example, you get a viral infection and you have a fever. That fever is really as a result of the inflammation that’s being caused by the immune system.

What we’re learning is that inflammation is in fact at the heart of atherosclerosis, which is basically at the heart of all heart disease, stroke, and heart attacks. White blood cells, many of them, are full of cholesterol, and they’ll start depositing. Over time, as these plaques build up, they result in blockages that can lead to heart attacks and strokes.

These very robust immune systems are in some ways like a post–Cold War nuclear arsenal, in which you don’t have that threat anymore, but these weapons are still lying around. That’s why we see all these autoimmune diseases, and also we see such a high prevalence of atherosclerosis.

[In a similar way,] even though our nutrition has changed a lot, adaptive mechanisms that were meant to protect us from starvation have now, in fact, led to the dual epidemics of obesity and diabetes, which are some of the main reasons why heart disease remains the number-one killer of people around the world.

Khazan: I noticed that heart-disease deaths are actually going up in certain parts of the country, in a reversal of course. Do you know why that is?

Warraich: There are two things that are happening. Many of the newest cohort that has entered older age in the United States are much more obese than people in the past. It is resulting in a lot of those people getting older and now dying from heart disease.

The other thing is—if you look at the paradox in heart disease, which is different from diseases such as cancer—for most heart disease, you actually have very, very effective ways of preventing and treating it. We have good medications, but we’re losing the battle for information and trust. Many people just don’t trust doctors when it comes to the prescriptions or the advice they give.

There’s still a lot of suspicion about very common, but very effective medications such as statins. We still have a lot of problems getting the right medications to the right people.

Warraich: [Studies show that even] patients who have already had heart attacks are not taking statins or are not on the appropriate dose of statins. That’s a huge deal.

One of the ways this manifests itself is in the so-called “nocebo effect.” The nocebo effect is the evil cousin of the placebo effect. If patients expect harm, or they expect something bad to happen, then that will, in fact, manifest itself in a very real and physical way. One of the things that is most commonly noted about statins is that they [supposedly] cause muscle aches and weakness.

If you look at randomized trials in which patients did not know if they were taking placebo or if they were taking statins, not a single large trial has shown increased prevalence of aches and weakness in patients taking statins.

Now that statins are well-known, many patients come in with this idea. They’ve talked to other people or they’ve heard on TV or they’ve read on the internet that statins cause a lot of symptoms. Patients come in overwhelmingly expecting that statins will not make them feel good.

We, as a scientific community, have to convince patients that they can trust us.

Khazan: Well, and at the same time, you said that experts have historically been very wrong about heart disease. What do you mean by that?

Warraich: When they first discovered blood pressure, physicians thought that high blood pressure was necessary for blood to reach the most remote or the most difficult-to-reach parts of the body.

It was actually the insurance companies who, in millions of their beneficiaries, are collecting data showing that high blood pressure was associated with more people dying. Yet, none of this information was ever followed by the scientific, the cardiology experts of their time.

It took almost decades of almost missionary zeal, not only from the insurance companies, but also from the researchers, to convince the established cardiology community that in fact treating high blood pressure was the right thing to do. Famous cardiologists like William Osler were almost militantly opposed to lowering blood pressure.

At one point, around the second World War, one in two Americans died of high blood pressure, but at that time the leading voices in cardiology actually felt that lowering blood pressure would do more harm than good. It wasn’t until the ’60s, ’70s, and ’80s when this mind-set was fully changed.

The question is, what are the false ideas that we believe today? An expert is someone who has mastery of current knowledge, not of future knowledge. I think we have to find a balance between having people who have expertise, but also understanding that not every time is an established idea the right thing.

As she stood in front of hundreds of gun-control advocates at a rally in Fort Lauderdale, Florida, late last month, the Marjory Stoneman Douglas High School senior Emma González told the audience that she and her peers should instead be at home grieving. Yet there González was, wiping tears from her eyes and delivering a now-viral speech demanding tougher gun laws in the U.S. A few days later, she would be questioning an NRA spokeswoman on CNN. And that was only her first week as a vanguard of a movement that’s spreading across the country with astonishing speed—and showing no signs of stopping.

That the Parkland student activists planted the seeds of their political campaign mere hours (even minutes) after the shooting that killed 17 people at their high school is, in part, what has made the movement so resonant to those watching it unfold. There’s something powerful in the fact that the people who will have the deepest scars from the events of February 14—people who would be expected to, say, be resting at home and mourning lost friends—are stepping up to do what, in their view, adults in the political sphere aren’t. It’s a response one journalist referred to as “courageous grieving.” But critics have also weaponized their emotional states to argue against the coherence of their minds and their movement. Bill O’Reilly asked on Twitter last Tuesday: “The big question is: Should the media be promoting opinions by teenagers who are in an emotional state and facing extreme peer pressure in some cases?”

Both O’Reilly’s criticism and the reverse—reactions that admire how quickly the students resorted to activism—rely on a sense that grief and political activism are not natural partners. These responses seem to imply that the Parkland students’ fervor is either so soon that it’s brave, or too soon and therefore unreliable. The students’ quick turn to action is neither uncommon in American history nor detrimental to the process of grief. But they are still grieving, and that grief could hit even harder as the buzz of interviews and rallies dies down and they settle back into their lives at school.

While the Parkland movement is for many reasons unique in the history of activism, the immediacy of the students’ action isn’t one of them. Angus Johnston, a City University of New York professor who studies the history of student activism, pointed out that American civil-rights activists would often turn to political organizing right after a lynching took place. The mother of Emmett Till, a 14-year-old black boy lynched in Mississippi in 1955, insisted on a public funeral; Till’s mother urged the public to look at his disfigured body, and the photographs and news coverage quickly spurred a national conversation on racism. Recent responses to police shootings of black men have also speedily taken on a political tone, Johnston said. The Parkland students are joining a long tradition of American mourners who channel their grief into political activism.

The Parkland students have been moving from candlelight vigils and friends’ funerals to CNN interviews and strategy sessions in each other’s living rooms. Sometimes grief and politics overlapped in the same moment, like when a chant of “no more guns!” broke out at a candlelight vigil the day after the shooting. Reading about the teens’ hectic and exhausting days, it’s hard not to worry: Can this really be healthy? Experts say it can, though they stress there are caveats.

The reasons for turning to political action in moments of grief are fairly intuitive: Humans naturally look to find some meaning in a painful and senseless event. It’s a way of continuing a story that has reached a sudden end, said Robin Gurwitch, a psychologist at Duke University Medical Center who specializes in children’s trauma. Gurwitch suggested that the question of whether it’s “too soon” to undertake activist work glosses over the nuances of grief. “Whenever that individual feels like, ‘I need to do something’ ... [this action] can be very helpful to the healing process,” she said. And it doesn’t have to be an either-or choice: “It is not as simple as a binary [of] ‘I can either be an advocate or ... be grieving,’” Gurwitch said.

After a traumatic event, a person has no choice but to move forward—where she might have a choice is in where she will move. The word “crisis” comes from the Greek krisis, which means ‘fork in the road’ or ‘decision,’ noted Stephen Brock, a professor of psychology at California State University, Sacramento, who has worked on issues of student trauma and grief. “When something like this happens, you can’t continue along your same path. You have to choose a new path.” And a person has lots of roads—healthy or dangerous or something in between—to choose from.

The healthiest roads entail what Brock called “active or approach-oriented coping”: “The person identifies that something bad happened, and they try to deal with it, to do something about it.” He sees the activism of the Parkland students as an example of this approach. It’s advisable for people of all ages to take some kind of action after a crisis or tragedy, he said, although the actions will look different depending on the age. For children, Brock said, taking action might mean writing condolence cards, or having conversations about caring for one another. But for adolescents, focusing on “broader social issues” is actually a commonly recommended form of crisis intervention. Activism can also be a particularly compelling path for adolescents, who even under normal circumstances are trying to find their place in society, show independence, and play a role in important conversations. According to Brock, the most unhealthy path for grievers is “avoidance coping,” when the person “tries to deny or minimize what happened.”

Part of what makes active coping so healthy is that it offers the person an opportunity to get some control back in a situation that’s otherwise totally out of her hands. And activism has its own particular benefits: People experiencing grief can find it helpful to stay connected to other people, to help others, and to be engaged in activities and routines. As Jaclyn Corin, a Douglas Stoneman student, told The New Yorker several days after the shooting, “My coping mechanism is to distract myself with work and helping people.”

Still, experts cautioned that activism isn’t a substitute for the grieving process. What the students are doing, Brock said, could facilitate a journey that will last a long time—likely their whole lives. “It might be putting them in a better position to grieve,” he said. But they still must grieve. And that’s where the adults and peers in their lives come in. The activism is helpful “only to the extent” that family and friends are around to help ensure that the students are doing the work of dealing with the long-term grief that’s ahead of them, Brock said. Parents can also help kids avoid any pressure they feel, from their peers or from themselves, to participate in the political movement or to process their grief in one particular way, by reminding them that there’s no single “right” way to grieve. Each student will also be dealing with a different set of challenges, from the grief of losing a family member or best friend to the trauma of the shooting itself.

The Parkland student activists clearly aren’t plowing past their emotions or avoiding the vulnerability that comes with grief; reporters have noted that some students had panic attacks or collapsed in tears during activism-strategy sessions. “Unfortunately the bad feelings and the reminders of everything that’s happened are coming at all the wrong times,” the 17-year-old Cameron Kasky told BuzzFeed the weekend after the shooting.

The Parkland students don’t seem to ascribe to the notion that it’s unnatural to turn to activism in the face of grief. For them, when it comes to gun control, political activism is its own act of mourning. As the Douglas high-school senior González put it, speaking to The New Yorker: “This is how I’m dealing with my grief. The thing that caused me grief, the thing that had no right to cause me grief, the thing that had no right to happen in the first place, I have to do something actively to prevent it from happening to somebody else.”

But it will still be important for friends and family to keep an eye on the students when things start to quiet down, said Melissa Reeves, a school psychologist and professor of psychology at Winthrop University who specializes in issues of trauma and crisis. She suggested that those close to the students watch for “delayed grief reactions” once the students are back to their day-to-day lives (which will start to be the case now that classes at Marjory Stoneman Douglas have resumed). Reeves also cautioned that the students might be disappointed if they don’t see impacts on the national level anytime soon, which could do them further damage.

The experts I spoke with said that while the Stoneman Douglas activists are of course contending with all the normal emotional and intellectual tolls that grief or trauma inflicts, those who critique them for being too young or too emotional aren’t giving them enough credit. “These young people are not that far removed from being adults,” Brock said. “With that comes, as appropriate, this kind of activism. This is the kind of thing adults did following Sandy Hook.”

Jeremy Richman, whose 6-year-old daughter Avielle Rose Richman was killed in the Sandy Hook shooting, remembers the hours following his daughter’s murder clearly. “You feel like you’re not just broken but you’re missing something that’s part of you,” he said. “You have to find some meaning or action to move, to get out of bed.” Almost immediately after the shooting, Richman and his wife, Jennifer Hensel, started thinking about what would become the Avielle Foundation, a nonprofit dedicated to preventing violence through research and community engagement.

“In a blurry 48 hours we created the mission and the vision of the foundation,” Richman said. “We knew exactly what we were going to do.” For Richman, taking action right away filled two roles: one personal and one public. On the personal level, it “motivate[d] us to get out of bed and move,” he said. But “in an outward-facing fashion, we were profoundly committed to preventing others from suffering in the way that we were suffering and continue to [suffer to] this day.” For Richman and his family, the inward and the outward were immediately intertwined. “It was right away, and it was really valuable, because we [could] process ... the whole experience with the passion, conviction, and energy that we had,” Richman said.

Richman is a neuroscientist, and he stressed the fact that adolescents like the Parkland students make for great activists. “Their brains are literally wired right now at such an exponentially greater extent than ours are in our adulthood,” he said. “They’re the perfect people to solve problems, take action, and have the passion to do it.” Those fluctuations of stress hormones that make cranky teens annoying to their parents, Richman said, can also be “a profoundly powerful motivator” for something a bit more grand—say, a movement they’re calling #NeverAgain.